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Last Updated

11 Jun 2003

Source: New York Times, November 11, 2001.

Bioterror Role an Uneasy Fit for Disease Centers

On the morning of Sept. 11, not long after terrorists crashed planes into the World Trade Center and the Pentagon, the Centers for Disease Control and Prevention in Atlanta received a worrisome tip from the F.B.I.: Another hijacked aircraft appeared headed for Atlanta and possibly the C.D.C., whose laboratories house some of the world's deadliest germs, including the only official repository of smallpox outside Russia.

Dr. Jeffrey P. Koplan, the agency's director, decided to evacuate. In Washington, his boss, Tommy G. Thompson, the secretary of health and human services, was concerned.

"What about the dangerous bugs?" Mr. Thompson asked his aides.

Mr. Thompson ordered Dr. Scott Lillibridge, an official at the centers whom the health secretary had just hired as his bioterrorism adviser, to ensure that the microbes were secure. Dr. Lillibridge, whose wife was at that moment going into labor with their first child, stayed behind, confirming that 32 security people were already in place to guard the facility and its biosafety labs.

The incident provides a telling glimpse into the thinking of officials at the disease control centers. While Mr. Thompson and his staff in Washington worried that terrorists might have been plotting to steal smallpox from the labs, the country's public health leaders felt comfortable relying on existing security measures. It was a sentiment that critics said reflected a culture that made fighting bioterrorism a lower priority than fighting the very real threat of naturally occurring diseases.

Although the disease control centers, at Congress's direction, started a bioterrorism initiative two years ago, nearly a dozen experts, including current and former government officials, said in interviews that its leaders, including Dr. Koplan, did not make the program a high enough priority. C.D.C. officials, these experts said, viewed bioterrorism as a distraction from public health matters that involved real diseases, not theoretical threats. And they did not want to be seen as an arm of law enforcement, a perception that could create mistrust as they investigated disease outbreaks overseas.

"It was something that they got money to do, and they were doing it," said Michael Moodie, president of the Chemical and Biological Arms Control Institute, a nonprofit research organization that studied the government's bioterrorism preparedness effort for Congress in 1999 and 2000. "But in terms of grasping the attention of the leadership, and an institutionwide sense that this was important, I didn't have the feeling that was the mentality there."

In an interview on Friday, Dr. Koplan dismissed that contention as "inconceivable." Bioterrorism, he said, "is something we have all spent considerable time on, including me, taking a personal role on this since the day I arrived. It's been a priority for our laboratories, our epidemiologic capability and our relationship with state and local health departments."

Now that anthrax has killed four Americans and sickened more than a dozen, the C.D.C., the nation's public health agency, has been thrust into a new and uncomfortable national security role. In recognition of that new role for the agency, President Bush last week became the first United States president to visit the disease control centers while in office.

The visit was an important morale booster for an agency that has been in overdrive to respond to the anthrax threat. Laboratories have been stressed to capacity, exhausted technicians have been sleeping in the labs, and the agency's epidemiologists, the disease detectives who track microbes around the world, have been working 18-hour days.

Dr. Koplan said he was especially proud that the agency had learned how to successfully treat inhalation anthrax, a deadly form of the disease that until the recent outbreak was universally regarded as fatal. And officials both inside and outside the government say that the C.D.C. has undoubtedly spared lives by moving quickly to contain the anthrax threat.

"They're a bunch of pros," said Dr. Anthony S. Fauci, director of the National Institute of Allergy and Infectious Diseases, "and they're a quite good at what they do."

Yet the agency has been subject to considerable criticism for its scientific and its political responses to the anthrax threat. On the scientific front, it failed to recognize that a particularly potent form of anthrax sent to Senator Tom Daschle, the Senate majority leader, would endanger postal workers in the nation's capital, two of whom died.

On the political front, state and public health officials and the news media have complained that agency leaders were inaccessible early in the outbreak, which confused the public and, more important, left doctors unsure how to respond.

"Where is the leadership?" asked one public health expert. "You can argue over the question of the postal workers and should they have known, or shouldn't they, but I think where they have undermined their own best efforts is in not being available to explain what they were doing and why, and what we don't know and how we hope to learn more."

Dr. Koplan, who said he has always tried to keep his contact with the press "in some kind of wraps," allowed that communications could have been better, and added that his first instinct was to focus on the science. "In the first couple of days, I did nothing, virtually, but be here and focus on working and what we were learning," he said. "I maybe should have been more visible during that time. I don't know."

Dr. Lillibridge, meanwhile, said, "We knew that communications would be important, but I don't think we knew that it would be this dominant in the response."

For example, Steven L. Abrams, the mayor of Boca Raton, Fla., where the first anthrax case occurred, said he spent an entire morning trying to find C.D.C. officials to determine if they were going to close down his city's post office.

In Washington, where the two postal workers died of anthrax, Dr. Ivan C. A. Walks, the city's chief health officer, said the C.D.C. "did as good a job as they knew how to do." But he added that the federal bureaucracy was slow when it came to approving official statements and health alerts.

"My concerns have to do with how quickly they can communicate," Dr. Walks said. "We would talk about something here in D.C., they would have to send everything down to Atlanta." He added, "Sometimes that took several hours to a day."

Partly as a result of such criticism, Mr. Thompson has taken additional steps to reorganize his agency's approach to bioterrorism. He now has daily conference calls that, one official said, have improved communications. He hired D. A. Henderson, a Johns Hopkins University professor best known for leading the worldwide effort to eradicate smallpox, to create and direct a new Office of Public Health Preparedness.

At the same time, Dr. Fauci, who proved adept at dealing with the press during the highly politicized early days of the AIDS epidemic, has emerged as the government's leading spokesman on bioterrorism.

That pleases lawmakers, among them Senator Hillary Rodham Clinton, Democrat of New York, who has been calling for a single bioterrorism spokesman. "We need authoritative information," she said, adding that she was not certain the disease control centers was the right agency for the role. "They're scientists who follow up on leads," she said. "I'm not sure that the public information role resides rightly with them."

But Representative Christopher Shays, the Connecticut Republican who heads the House Government Reform Committee's subcommittee on national security, said the agency would have to step into the spotlight more often now.

"The terrorists made C.D.C. far more important than it was before Sept. 11," Mr. Shays said. "They're dealing with some very significant issues and I think they are not used to being in the public limelight, but they are going to have to get used to it."

Mr. Shays added: "We're going to have to change their culture a little bit. They need to be more public, and they need to be more involved in our national defense."

If there is anything the C.D.C. is known for, it is its corps of epidemiologists, the celebrated disease detectives who travel the world tracking exotic germs. Established 50 years ago after the Korean War, the corps was intended to act as an early warning system, not only against natural epidemics but also against biological warfare. Thus its name, the Epidemic Intelligence Service.

By 1972, however, when the United States signed an international pact agreeing to abandon the development of germs as weapons, the threat of a biological war seemed to recede.

While the Army maintained an infectious disease laboratory at Fort Detrick, Md., to develop defenses against germ attacks, the C.D.C. kept its distance from the effort.

"They felt they were trained, in essence, to save lives where the defense people were more trained to deal with military type actions," one official said. "They didn't want to see the world's best public health system somehow sullied by too close an association with people who carried guns and were spies."

In 1998, Dr. Margaret Hamburg, who had been preparing for bioterrorism when she was New York City health commissioner, joined the Health and Human Services Department. She pressed that agency to start a bioterrorism initiative and to ask Congress for money.

The initial appropriation to the agency from Congress, awarded in fiscal year 1999, was $122 million. That amount has since grown to $181 million, but Dr. Lillibridge said agency officials were concerned, early on, that the program would not be renewed beyond a year.

The money was broken into three parts, Dr. Lillibridge said. Roughly a third went to creating the National Pharmaceutical Stockpile, a cache of medicines and medical supplies that is now being used in the anthrax response. Another third went to the states, to build up a network of 81 public health laboratories and create a communications system, the health alert network, that links state and local health agencies to the C.D.C. The final third, he said, went to what he called C.D.C. internal activities, upgrading labs and paying for staff for the health alert network.

But Dr. Lillibridge did not have control over the entire program; he was stationed in the infectious diseases branch of the C.D.C., while other components, including the pharmaceutical stockpile, an essential element of biodefense, were run out of different branches.

Mr. Moodie, who conducted the study of the government's bioterrorism response, said he recommended that Dr. Lillibridge's program "be put in the director's office." But the recommendation, he said, was not adopted.

When Mr. Thompson, a governor with little scientific experience, took over as health secretary in January, there was an immediate culture clash, those close to the health secretary say. When Mr. Thompson visited the C.D.C. before Sept. 11 for an hourlong briefing, "bioterrorism got about two minutes at the very end of the session," said one official who was later briefed on the visit. The secretary came to see the agency and the scientists who ran it as too much like university professors, unable to make snap decisions in a time of crisis.

Mr. Thompson moved to bring in his own experts, including Dr. Lillibridge, whose baby will be 2 months old today. Dr. Lillibridge says he now expects to shuttle back and forth between Washington and Atlanta to help preside over what will likely be a "dramatic expansion" of the C.D.C.'s bioterrorism effort. He said he sensed a new closeness between law enforcement and public health officials who have been forced to work together during the anthrax attacks.

"The F.B.I." he said, "returns my phone calls on a moment's notice."